{"id":18630,"date":"2024-05-21T07:30:00","date_gmt":"2024-05-21T07:30:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=18630"},"modified":"2024-06-06T16:26:57","modified_gmt":"2024-06-06T16:26:57","slug":"sangramento-pos-drenagem-endoscopica-de-necrose-pancreatica","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/sangramento-pos-drenagem-endoscopica-de-necrose-pancreatica\/","title":{"rendered":"Sangramento p\u00f3s-drenagem endosc\u00f3pica de necrose pancre\u00e1tica"},"content":{"rendered":"\n

Introdu\u00e7\u00e3o<\/strong><\/h2>\n\n\n\n

A pancreatite aguda necrotizante \u00e9 respons\u00e1vel por at\u00e9 10% dos casos de pancreatite aguda. A necrose do tecido pancre\u00e1tico, peripancre\u00e1tico ou ambos, permanece est\u00e9ril na maioria dos pacientes, entretanto cerca de 30% dos pacientes apresentam infec\u00e7\u00e3o da cole\u00e7\u00e3o necr\u00f3tica (WON), condi\u00e7\u00e3o cl\u00ednica que imp\u00f5e alta mortalidade. Evolu\u00e7\u00e3o com fal\u00eancia de \u00f3rg\u00e3os, colangite ou necessidade de debridamento cir\u00fargico de WON infectado s\u00e3o fortes preditores de mortalidade, o que torna prudente a ado\u00e7\u00e3o de estrat\u00e9gias terap\u00eauticas minimamente invasivas para o tratamento dessa complica\u00e7\u00e3o (1).<\/p>\n\n\n\n

Na \u00faltima d\u00e9cada o conceito de estrat\u00e9gia minimamente invasiva do tipo \u201cstep-up approach\u201d <\/em>tornou-se amplamente utilizado e corroborado pela Associa\u00e7\u00e3o Americana de Gastroenterologia (2). A drenagem endosc\u00f3pica transluminal associada ou n\u00e3o \u00e0 necrosectomia consolidou-se como a terap\u00eautica de primeira escolha na abordagem de pancreatite aguda necrotizante complicada.  Essa via de interven\u00e7\u00e3o apresenta menor incid\u00eancia de descompensa\u00e7\u00e3o cl\u00ednica por fal\u00eancia de \u00f3rg\u00e3os, f\u00edstulas e perfura\u00e7\u00e3o quando comparada \u00e0s t\u00e9cnicas cir\u00fargicas e por radiologia intervencionista minimamente invasivas (3).<\/p>\n\n\n\n

T\u00e9cnica Endosc\u00f3pica<\/strong><\/h2>\n\n\n\n

A primeira experi\u00eancia de drenagem endosc\u00f3pica de necrose pancre\u00e1tica remete ao final da d\u00e9cada de 1980 e descrevia a utiliza\u00e7\u00e3o de endosc\u00f3pico convencional, adotando como refer\u00eancia para pun\u00e7\u00e3o a impress\u00e3o criada pela cole\u00e7\u00e3o sobre a parede g\u00e1strica. Com o passar dos anos a t\u00e9cnica de drenagem guiada por ecoendoscopia tornou-se a modalidade de escolha para o procedimento, o que permitiu alta taxa de sucesso na cria\u00e7\u00e3o do trajeto at\u00e9 a cole\u00e7\u00e3o, identifica\u00e7\u00e3o de vasos sangu\u00edneos, distribui\u00e7\u00e3o da cole\u00e7\u00e3o e janela adequada para a pun\u00e7\u00e3o (4,5)<\/p>\n\n\n\n

Recomenda-se aguardar per\u00edodo de pelo menos 4 semanas at\u00e9 a primeira interven\u00e7\u00e3o, o que permite encapsula\u00e7\u00e3o e delineamento das margens da cole\u00e7\u00e3o necr\u00f3tica. Entretanto na vig\u00eancia de infec\u00e7\u00e3o, fal\u00eancia org\u00e2nica persistente ou aus\u00eancia de melhora cl\u00ednica a despeito das interven\u00e7\u00f5es cl\u00ednicas institu\u00eddas, \u00e9 assertivo realizar a primeira interven\u00e7\u00e3o em intervalo menor (2).<\/p>\n\n\n\n

A via de drenagem endosc\u00f3pica, transg\u00e1strica ou transduodenal, \u00e9 definida de acordo com a localiza\u00e7\u00e3o do maior componente da cole\u00e7\u00e3o necr\u00f3tica (cabe\u00e7a, corpo ou cauda) e a rela\u00e7\u00e3o com o est\u00f4mago e duodeno. N\u00e3o existe diferen\u00e7a em termos de sucesso terap\u00eautico ou seguran\u00e7a entre as vias, embora a drenagem transg\u00e1strica permita acesso direto \u00e0 cole\u00e7\u00e3o na necessidade de necrosectomia. O trajeto de drenagem pode ser assegurado por meio de Lumen-apposing metal stents<\/em> (LAMS) ou double pigtail stents <\/em>(DPS), de acordo com disponibilidade do stent, experi\u00eancia do endoscopista e fatores econ\u00f4micos, sem diferen\u00e7a no sucesso terap\u00eautico (6).<\/p>\n\n\n\n

Eventos adversos e sangramento<\/strong><\/h2>\n\n\n\n

Apesar da efetividade cl\u00ednica da drenagem endosc\u00f3pica, a incid\u00eancia de eventos adversos n\u00e3o \u00e9 desprez\u00edvel. Infec\u00e7\u00e3o, perfura\u00e7\u00e3o, migra\u00e7\u00e3o de stent e hemorragia ocorrem em at\u00e9 20% dos casos.<\/p>\n\n\n\n

A ocorr\u00eancia de sangramento \u00e9 frequentemente descrita nas s\u00e9ries hist\u00f3ricas e nos cl\u00e1ssicos trabalhos que ratificam o tratamento endosc\u00f3pico em termos de efic\u00e1cia e seguran\u00e7a, tipo de pr\u00f3tese e tempo para abordagem da cole\u00e7\u00e3o necr\u00f3tica. Entretanto s\u00e3o escassos os dados sobre etiologia do sangramento, abordagem adotada para hemostasia definitiva e os desfechos fatais (7).<\/p>\n\n\n\n

Fatores de risco associados a sangramento<\/strong><\/h2>\n\n\n\n

O desafio do manejo de sangramento nessa popula\u00e7\u00e3o motivou a publica\u00e7\u00e3o de dois recentes estudos retrospectivos, que avaliaram fatores preditores de sangramento nos pacientes submetidos \u00e0 necrosectomia endosc\u00f3pica. Zheng et al. estudaram 145 pacientes, dos quais 39 (26.9%) apresentaram sangramento p\u00f3s-procedimento. A maioria dos epis\u00f3dios de sangramento (94.1%) foi efetivamente controlado com terapia hemost\u00e1tica endosc\u00f3pica. Na an\u00e1lise multivariada, insufici\u00eancia renal, necrose infectada confirmada por cultura e tr\u00eas ou mais sess\u00f5es de debridamento foram associados a maior risco de sangramento (9). Holmes et al. estudaram 151 pacientes, dos quais 18 (11.9%) apresentaram sangramento. Tratamento por radiologia intervencionista foi necess\u00e1rio para 8 pacientes. Na an\u00e1lise multivariada somente a presen\u00e7a de vaso identificado durante a necrosectomia endosc\u00f3pica se mostrou fator de risco para sangramento (10).<\/p>\n\n\n\n

Apesar de in\u00fameras publica\u00e7\u00f5es que n\u00e3o revelaram diferen\u00e7a significativa na ocorr\u00eancia de sangramento entre os tipos de stents utilizado (LAMS x DPS x Fully covered metal stent<\/em>), questionamentos sobre os dispositivos s\u00e3o frequentemente levantados. Especula-se que a r\u00e1pida descompress\u00e3o da cole\u00e7\u00e3o atrav\u00e9s do LAMS predisp\u00f5e \u00e0 eros\u00e3o de vasos adjacentes e hemorragia. Al\u00e9m disso o maior di\u00e2metro do LAMS permitiria maior influxo de secre\u00e7\u00e3o g\u00e1strica \u00e1cida para o interior da cole\u00e7\u00e3o, o que aumentaria a exposi\u00e7\u00e3o de vasos e o risco de sangramento (para saber mais sobre LAMS clique aqui<\/a>). N\u00e3o obstante, os stents pl\u00e1sticos possuem menor di\u00e2metro, exigem maior n\u00famero de sess\u00f5es de debridamento e s\u00e3o mantidos em posi\u00e7\u00e3o por mais tempo, tamb\u00e9m aumentando o risco de hemorragia (7).<\/p>\n\n\n\n

O sangramento pode se originar do s\u00edtio de pun\u00e7\u00e3o, da pr\u00f3pria parede g\u00e1strica ou duodenal, ramos colaterais g\u00e1stricos ou duodenais, ou ainda vasos no interior da cavidade da cole\u00e7\u00e3o necr\u00f3tica (WON). Menos comumente, os pseudoaneurismas de art\u00e9rias viscerais imp\u00f5em devido risco eminente de sangramento fatal. A utiliza\u00e7\u00e3o de TC de abdome com contraste na fase arterial permite a identifica\u00e7\u00e3o de pseudoaneurisma e o tratamento preemptivo dessa condi\u00e7\u00e3o, de modo a diminuir os riscos de sangramento periprocedimento (11).<\/p>\n\n\n\n

Al\u00e9m das particularidades anat\u00f4micas, a irriga\u00e7\u00e3o do tecido necr\u00f3tico com per\u00f3xido de hidrog\u00eanio tem maior risco de sangramento p\u00f3s-procedimento quando comparado a solu\u00e7\u00e3o de estreptoquinase nas sess\u00f5es de debridamento (12).<\/p>\n\n\n\n

Abordagem terap\u00eautica de sangramento<\/strong><\/h2>\n\n\n\n

Do ponto de vista terap\u00eautico, o sangramento associado \u00e0 drenagem endosc\u00f3pica de WON pode ser dividido em sangramento intra-procedimento ou sangramento p\u00f3s-procedimento. \u00c9 fundamental que antes de iniciar o tratamento endosc\u00f3pico de WON, a equipe envolvida certifique-se da disponibilidade de leito de terapia intensiva, reserva de hemocomponentes e retaguardas de radiologia intervencionista e cirurgia, e encontre-se preparada para a abordagem imediata da complica\u00e7\u00e3o (4).<\/p>\n\n\n\n

Quando identificado sangramento durante o procedimento, a severidade da perda sangu\u00ednea orientar\u00e1 a abordagem. Em caso de sangramento autolimitado e de pequeno volume, \u00e9 aceit\u00e1vel a admiss\u00e3o em terapia intensiva no p\u00f3s-operat\u00f3rio imediato, com avalia\u00e7\u00e3o cl\u00ednica e monitoriza\u00e7\u00e3o seriada dos n\u00edveis de hematimetria. Diferentemente, em caso de perda de volume sangu\u00edneo significativo, terapias endosc\u00f3picas de hemostasia (clipe met\u00e1lico, cauteriza\u00e7\u00e3o, agente t\u00f3pico, tamponamento com bal\u00e3o dilatador ou pr\u00f3tese met\u00e1lica) devem ser avaliadas e aplicadas no intraoperat\u00f3rio. Na falha terap\u00eautica, o paciente deve ser encaminhado \u00e0 radiologia intervencionista ou cirurgia imediatamente.<\/p>\n\n\n\n

Na ocorr\u00eancia de sangramento p\u00f3s-procedimento, deve-se al\u00e9m de pesquisar altera\u00e7\u00f5es endosc\u00f3picas e anat\u00f4micas que o justifiquem, dist\u00farbios da coagula\u00e7\u00e3o que possam precipitar o evento adverso. Na presen\u00e7a de les\u00e3o trat\u00e1vel por endoscopia, devem ser aplicados os princ\u00edpios de hemostasia endosc\u00f3pica. Na presen\u00e7a de aneurismas, pseudoaneurismas ou falha endosc\u00f3pica, a abordagem por radiologia intervencionista deve ser programada.<\/p>\n\n\n\n

Diante da experi\u00eancia acumulada por diferentes grupos, Jiang et al. propuseram um algoritmo para manejo multidisciplinar de hemorragia na drenagem por ecoendoscopia de cole\u00e7\u00f5es fluidas peripancre\u00e1ticas (Figura 1). O tratamento de cole\u00e7\u00e3o necr\u00f3tica infectada \u00e9 moroso e exige habilidades t\u00e9cnicas nos campos da cl\u00ednica, cirurgia, endoscopia e radiologia. A difus\u00e3o da pr\u00e1tica de drenagem endosc\u00f3pica gerou aten\u00e7\u00e3o para complica\u00e7\u00f5es inerentes ao procedimento, incluindo o sangramento. O emprego da terapia endosc\u00f3pica ciente dos fatores de risco para sangramento e estrat\u00e9gias para trat\u00e1-lo permitem efetividade com menor incid\u00eancia de eventos adversos.<\/p>\n\n\n

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Refer\u00eancias<\/strong><\/h2>\n\n\n\n
    \n
  1. Podda M, Pellino G, Di Saverio S, Coccolini F et al. Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA\u20111 international study. Updates in Surgery<\/em> 2023; 75:493\u2013522<\/li>\n\n\n\n
  2. Baron TH, DiMaio CJ, Wang AY et al. American Gastroenterological Association Clinical Practice Update: Management of pancreatic necrosis. Gastroenterology <\/em>2020; 158: 67\u201375<\/li>\n\n\n\n
  3. Bang JY, Wilcox CM, Arnoletti JP et al. Superiority of endoscopic interventions over minimally invasive surgery for infected necrotizing pancreatitis: meta-analysis of randomized trials. Dig Endosc <\/em>2020; 32: 298\u2013308<\/li>\n\n\n\n
  4. Baron TH, Thaggard WG, Morgan DE, Stanley RJ. Endoscopic Therapy for Organized Pancreatic Necrosis. Gastroenterology<\/em> 1996;111:755 \u2013764.<\/li>\n\n\n\n
  5. Varadarajulu, S.; Christein, J.D.; Tamhane, A.; Drelichman, E.R.; Wilcox, C.M.Prospective Randomized Trial Comparing EUS and EGD for Transmural Drainage of Pancreatic Pseudocysts (with Videos). Gastrointest. Endosc.<\/em> 2008; 68<\/em>, 1102\u20131111.<\/li>\n\n\n\n
  6. Bang JY, Wilcox CM, Navaneethan U, Hawes RH, Varadarajulu S. Treatment of walled-off necrosis using lumen-apposing metal stents versus plastic stents: a systematic review and meta- analysis of data from randomized trials. Endoscopy<\/em> 2023; 56: 184-195<\/li>\n\n\n\n
  7. Jiang TA & Xie LT. Algorithm for the multidisciplinary management of hemorrhage in EUS-guided drainage for pancreatic fluid collections. World J Clin Cases <\/em>2018; 6(10): 308-321<\/li>\n\n\n\n
  8. Rana SS, Shah J, Kang M, et al. Complications of endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections and their management. Ann Gastroenterol <\/em>2019;32:441-50.<\/li>\n\n\n\n
  9. Zheng X, Li L, Li J, et al. Risk factors for bleeding in patients with acute necrotizing pancreatitis undergoing endoscopic necrosectomy. HPB<\/em> (Oxford) 2021;23(12):1856\u2013186<\/li>\n\n\n\n
  10. Holmes I, Shinn B, Mitsuhashi S, et al. Prediction and management of bleeding during endoscopic necrosectomy for pancreatic walled-off necrosis: results of a large retrospective cohort at a tertiary referral center. Gastrointest Endosc<\/em> 2022;95(03): 482\u2013488<\/li>\n\n\n\n
  11. Sekikawa Z, Yamamoto T, Aoki R, et al. Prophylactic Coil Embolization of the Vessels for Endoscopic Necrosectomy in Patients with Necrotizing Pancreatitis. J Vasc Interv Radiol. 2019 Jan;30(1):124-126. doi: 10.1016\/j.jvir.2018.05.025. PMID: 30580813.<\/li>\n\n\n\n
  12. Bhargava MV, Rana SS, Gorsi U, Kang M, Gupta R.  Assessing the Efficacy and Outcomes Following Irrigation with Streptokinase Versus Hydrogen Peroxide in Necrotizing Pancreatitis: A Randomized Pilot Study. Dig Dis and Sciences <\/em>2022; 67(8): 4146-53<\/li>\n<\/ol>\n\n\n\n

    Como citar este artigo<\/strong><\/h2>\n\n\n\n

    Ide E. e Nascimento Filho Hm. Sangramento p\u00f3s-drenagem endosc\u00f3pica de necrose pancre\u00e1tica. Terap\u00eautica Endosc\u00f3pica 2024 vol 1. Dispon\u00edvel em: https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/sangramento-pos-drenagem-endoscopica-de-necrose-pancreatica\/<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

    Introdu\u00e7\u00e3o A pancreatite aguda necrotizante \u00e9 respons\u00e1vel por at\u00e9 10% dos casos de pancreatite…<\/p>\n","protected":false},"author":5532,"featured_media":18631,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151,741],"tags":[409,757],"ano":[742],"tipo":[154],"volume":[263],"class_list":["post-18630","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","category-traduzir","tag-eus","tag-won","ano-742","tipo-ecoendoscopia","volume-volume-i"],"yoast_head":"\nSangramento p\u00f3s-drenagem endosc\u00f3pica de necrose pancre\u00e1tica • Endoscopia Terapeutica<\/title>\n<meta name=\"description\" content=\"Sangramento p\u00f3s-drenagem endosc\u00f3pica de necrose pancre\u00e1tica\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/sangramento-pos-drenagem-endoscopica-de-necrose-pancreatica\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Sangramento p\u00f3s-drenagem endosc\u00f3pica de necrose pancre\u00e1tica\" \/>\n<meta property=\"og:description\" content=\"Introdu\u00e7\u00e3o A pancreatite aguda necrotizante \u00e9 respons\u00e1vel por at\u00e9 10% dos casos de pancreatite aguda. 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